Diary from a Week in Practice

Am Fam Physician. 1998 Jan 15;57(2):263-264.

Monday

Husbands often give their wives the oddest presents. This year, JRH, after much thought and discussion, purchased a pressure washer that he and his wife had talked about buying for some time. Here in Florida, the uses for such tools are many and varied, because of the high humidity that allows algae to grow with a policy of eminent domain. No sooner than when JRH finished assembling it did his wife begin to clean the deck, the siding and the sidewalks. Unfortunately, one of her eyes began bothering her toward the end of the afternoon project and continued throughout the evening. A quick trip to the office for a Pontocaine-aided examination revealed the culprit—a speck of algae nestled underneath the upper lid. A quick rinse and removal of the speck provided the needed relief. The next time JRH buys such a present, he will consider adding on a needed accessory—safety glasses.

Tuesday

One of the most difficult aspects of being a family physician is helping the patient decide when it is time to say no. Today, a 78-year-old man with diabetes, arteriosclerotic heart disease, a bladder mass and a 7.4-cm abdominal aortic aneurysm presented with his wife to discuss his options. During an earlier routine examination, SEF had discovered a rather large pulsatile abdominal mass and gross hematuria. Evaluation for both problems began and eventually led to a cardiac examination including a cardiac catheterization, which showed three-vessel disease. Both the vascular surgeon and the urologist wanted to operate, but both required that he have a coronary artery bypass first. The patient was not sure if he wanted to continue with any of it. He had discussed his options not only with his wife but also with the rest of his family and came in today to make a final decision. After extensive discussion of the pros and cons of the surgeries facing this gentleman, as well as the recuperation required and the quality of life he would have, with the help of his family and prayer, he decided to forego any further treatment. A living will was discussed, and he was given some informational handouts. Although it is difficult for a physician to accept, sometimes the best option is to let nature take its course.

Wednesday

TBS finds providing maternity care to be one of the most rewarding parts of medical practice, but today presented an unusual experience. TBS had been following a 19-year-old woman during her second pregnancy. This second pregnancy was complicated by the finding of a congenital heart condition in the fetus, and plans were made for the patient to deliver at a specialty hospital in Orlando. Because of transportation problems, the patient was continuing her prenatal care with TBS in consultation with a perinatologist and a pediatric cardiologist. Now at 36 weeks of gestation, the patient came into the office with regular contractions and was found to be dilated to 6 cm. She was given Terbutaline, and an ambulance was called. The decision was made to transfer the patient by helicopter to Orlando. TBS was able to stay with her patient, helping to keep her calm, and she rode with her in the ambulance to meet the helicopter. The patient was then transported to Orlando, reaching the hospital in 10 minutes and delivering 30 minutes later. Although disappointed that she could not attend the delivery, TBS was comforted in knowing she had done everything possible to ensure that mother and infant received the care they needed. Indeed, she practiced the best of family medicine—providing excellent care and coordinating specialty care when needed by the patient.

Thursday

The joys of having a toddler are numerous, both in JRL's personal life and professional life. A distraught mom of a toddler presented with her child today. She had given him a handful of shelled peanuts on his high chair. The next thing the mom knew, her son put one large peanut up his left nostril. The mom stated that the boy became frightened when he placed the peanut up his nose and held his breath. His lips turned blue. However, after calming down, he regained his normal color. The mom brought the child to see JRL. Using bayonet forceps and alligator clamps, the foreign body was removed from the nares and the obstruction was relieved. It is nice to know that kids will be kids and that it is always good to have a long pair of forceps on hand for such an occasion.

Friday

While doing a colposcopy, TBS sometimes has to do electrocautery; however, she has often been concerned about the amount of cramping and pain the electrocautery can cause, despite premedication with 800 mg of ibuprofen. During a recent conference on women's health, TBS learned a simple technique that she tried today. After the initial inspection of the cervix with acetic acid, TBS placed a small cotton-tipped applicator, which had been sprayed with Hurricane spray, into the cervical os for one minute to provide local anesthesia. The electrocauterization was then performed and was well tolerated. TBS plans to use this technique with all electrocauterizations in the future.

Saturday/Sunday

For years, WLL has believed strongly, as do most family physicians, in the rights of patients exceeding the rights of the “medical system.” After all, the core role of family physicians, in our opinion, is that of an ongoing patient advocate. We've told you in the past about our admiration for Lynn P. Carmichael, M.D., one of the fathers of our specialty who has not only influenced our practice but also influenced JRH to choose family medicine as a career. Anyway, recently we saw the publication of Dr. Carmichael's “Medical Miranda” rights in the September/October 1997 issue of Archives of Family Medicine (p. 422). He not only posts these prominently in his office at the University of Miami Department of Family Medicine but also discusses them as part of his health maintenance review with patients. The rights are: “Patients have the right: to receive all pertinent treatment information and to discuss options, to refuse or accept medical care, to expect courtesy and respect, to confidentiality, to continuity of care and to have adequate medical care.”

This is one in a series by Walter L. Larimore, M.D., John R. Hartman, M.D., Theresa B. Shupe, M.D., Jonathan R. Lim, M.D., and Stephanie E. Frisbie, M.D., five family physicians in private practice in Kissimmee, Fla.


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